Electromechanical-assisted training for walking after stroke

Robot-assisted gait training for individuals with severe acquired brain injury: a scoping review

INTRODUCTION

Early out-of-bed mobilization is recommended for individuals with severe acquired brain injury and impaired consciousness to promote recovery. Robot-assisted gait training (RAGT) utilizes robotic assistance to facilitate neuroplastic changes through repetitive training and feedback. We aimed to map the evidence of RAGT in non-ambulatory individuals with impaired consciousness or cognitive functioning, focusing on the rationales underpinning its use and the assessment methods employed.

METHOD

Following the Joanna Briggs Institute and PRISMA scoping review guidelines, we systematically searched for studies involving adults with severe acquired brain injury. Source selection, data extraction, and charting were performed in duplicate.

RESULTS

Out of 10 444 records screened, seven were included, involving 162 participants. The studies included one randomized and two non-randomized clinical trials, two retrospective studies, and two case reports. RAGT aimed to improve physical recovery (n = 6), arousal stimulation (n = 4), and safety (n = 4). Twenty-six outcome measures were reported.

CONCLUSION

Our review highlights a research gap in RAGT for individuals with severe brain injury and cognitive impairments. Specifically, the underlying rationales need investigation, and standardized outcome measures must be established. RAGT shows potential in improving functional recovery and consciousness, but future studies must address safety, and feasibility while navigating ethical challenges.

Hands-free Atalante exoskeleton in post-stroke gait and balance rehabilitation: a safety study

BACKGROUND

Stroke often results in gait dysfunction, impairing daily activities and quality of life. Overground robotic exoskeletons hold promise for post-stroke rehabilitation. This study primarily aimed to assess the safety of hands-free Atalante exoskeleton training in post-stroke subjects, with a secondary aim to assess gait and balance.

METHODS

Forty subjects (10.2 ± 12.1 months post-stroke) with gait dysfunction (Functional Ambulation Category [FAC] score ≤ 3) underwent five training sessions over three weeks with a hands-free exoskeleton (Atalante, Wandercraft, France). Safety, the primary outcome, was evaluated by the number and severity of adverse events (AEs), judged by an independent clinical evaluation committee (CEC). A usability test was performed during the fifth training session followed by the exoskeleton use questionnaire. Gait and balance were assessed pre/post-training via walking capacity score (FAC), gait speed by 10-meter walk test (10MWT), walked distance by 6-minute walk test (6MWT), and balance by Berg Balance Scale (BBS). Spasticity was assessed with the Modified Ashworth scale. Anxiety and depression were quantified using the Hospital Anxiety and Depression Scale. Safety outcomes were analyzed using the Wilson, Lee and Dubin methods for proportions, and occurrence rates were computed. Within-group differences were compared using Wilcoxon, McNemar, and Friedman tests, with significance set at P < 0.05.

RESULTS

Thirty-one subjects completed the training sessions, while nine discontinued. The study reported two serious adverse events (SAE) (vertigo, dysarthria) and six AEs, with the CEC concluding that no SAE was linked to the device/study procedure. The average AE rate per session was 2.5 ± 1.4%, including four events possibly linked to the device/study procedure (knee pain [n = 1], skin lacerations [n = 3]), classified as negligible or minor by the CEC. A high proportion (82.6%) successfully completed the usability test and reported satisfaction (90%) on the exoskeleton use questionnaire. For gait and balance, favorable changes were observed in FAC, 10MWT, 6MWT, and BBS scores Post-training (p < 0.05, respectively). Spasticity, anxiety, and depression remained unchanged.

CONCLUSIONS

This study indicates that the hands-free Atalante exoskeleton is safe, feasible, and well-tolerated for gait and balance rehabilitation in post-stroke subjects, warranting larger randomized controlled trials to assess its efficacy.

TRIAL REGISTRATION

Evaluation of the Use of the Atalante Exoskeleton in Patients Presenting an Hemiplegia Due to Cerebrovascular Accident (INSPIRE) trial was registered at ClinicalTrials.gov (NCT04694001, registered on 20201231).

Flexible exoskeleton-assisted training enhances lower limb motor function after stroke: a systematic review and meta-analysis

BACKGROUND

Recent advances in flexible exoskeleton technology have broadened its application in stroke rehabilitation, particularly for improving motor functions in the affected lower limb. This review examines the impact of flexible exoskeleton-assisted training (FEAT) compared to conventional therapy on balance, motor functions, and gait parameters in post-stroke patients.

METHODS

We conducted a meta-analysis using data from randomized controlled trials (RCTs) identified through database searches and manual screening, focusing on outcomes such as balance (Berg Balance Scale, BBS), lower limb motor functions (Ten-Meter Walk Test, 10MWT; Six-Minute Walk Test, 6MWT; Functional Ambulation Category, FAC), and gait parameters (walking speed, step length, cadence, and symmetry).

RESULTS

This meta-analysis included 6 studies with 213 patients. FEAT significantly enhanced BBS scores, and performances on the 10MWT and 6MWT, along with other gait parameters; however, FAC scores did not improve significantly. Subgroup analyses revealed that FEAT with hip assistance significantly improved step length, cadence, and gait symmetry ratio, while ankle assistance improved performance on the 10MWT and 6MWT. FEAT was especially effective in improving step length, cadence, and gait symmetry ratio in patients with a post-stroke duration exceeding three months.

CONCLUSION

Compared to the conventional therapy, FEAT markedly improves the balance, walking ability, and gait parameters in stroke rehabilitation. These findings support the value of FEAT in lower extremity rehabilitation post-stroke, suggesting its integration into clinical programs could enhance the therapy effectiveness or efficiency. In addition, the appropriate type of FEAT needs to be selected in the rehabilitation program based on the patient's specific impairment. For example, FEAT with hip assistance may be recommended for stroke patients with severe gait asymmetry, aiding the development of personalized interventions.

Effects of robot-assisted gait training within 1 week after stroke onset on degree of gait independence in individuals with hemiparesis: a propensity score-matched analysis in a single-center cohort study

BACKGROUND

Robot-assisted gait training (RAGT) is an effective method for treating gait disorders in individuals with stroke. However, no previous studies have demonstrated the effectiveness of RAGT in individuals with acute stroke. This study aimed to investigate the effects of RAGT initiation within 1 week after onset on degree of gait independence in individuals with hemiparetic stroke.

METHODS

This retrospective cohort study used propensity-score matching. Individuals admitted to Fujita Health University Hospital after stroke onset and underwent RAGT between March 2017 and June 2023 were enrolled. Ninety-two individuals were eligible and grouped into the acute (≤ 7 days after the onset) and subacute groups (8-90 days after onset). RAGT was conducted using Welwalk, primarily comprising a knee-ankle-foot orthosis type robot worn on one paralyzed lower extremity, with training sessions lasting approximately 40 min/day, occurring 3-7 days/week. The primary outcome was the gait under supervision within 90 days of onset, which was compared between groups using the log-rank test.

RESULTS

After propensity-score matching, 36 individuals were included in the analysis, including 18 each in the acute and subacute groups; the participant demographics were not significantly different between the groups. RAGT was initiated at a median of 6 and 25 days after onset in the acute and subacute groups, respectively. The Kaplan-Meier curves after the log-rank test showed a significantly higher percentage and shorter median days to achieve gait under supervision in the acute group than in the subacute group. The cumulative incidence of gait under supervision events at 90 days after onset was 82.2% and 55.6% in the acute and the subacute groups, respectively. Half of the individuals achieved gait under supervision within 49 days and 75 days in the acute and subacute groups, respectively (p = 0.038). No significant differences were observed in the dose of rehabilitation program and gait training per day from onset to achieving gait under supervision.

CONCLUSION

Initiation of RAGT within 1 week after stroke onset in individuals with hemiparesis may reduce the number of days required to achieve gait under supervision and increase the percentage of gait under supervision.

Physical rehabilitation approaches for the recovery of function and mobility following stroke

BACKGROUND

Various approaches to physical rehabilitation to improve function and mobility are used after stroke. There is considerable controversy around the relative effectiveness of approaches, and little known about optimal delivery and dose. Some physiotherapists base their treatments on a single approach; others use components from several different approaches.

OBJECTIVES

Primary objective: To determine whether physical rehabilitation is effective for recovery of function and mobility in people with stroke, and to assess if any one physical rehabilitation approach is more effective than any other approach.

SECONDARY OBJECTIVE

To explore factors that may impact the effectiveness of physical rehabilitation approaches, including time after stroke, geographical location of study, intervention dose/duration, intervention provider, and treatment components. Stakeholder involvement: Key aims were to clarify the focus of the review, inform decisions about subgroup analyses, and co-produce statements relating to key implications.

SEARCH METHODS

For this update, we searched the Cochrane Stroke Trials Register (last searched November 2022), CENTRAL (2022, Issue 10), MEDLINE (1966 to November 2022), Embase (1980 to November 2022), AMED (1985 to November 2022), CINAHL (1982 to November 2022), and the Chinese Biomedical Literature Database (to November 2022).

SELECTION CRITERIA

Inclusion criteria: Randomised controlled trials (RCTs) of physical rehabilitation approaches aimed at promoting the recovery of function or mobility in adult participants with a clinical diagnosis of stroke.

EXCLUSION CRITERIA

RCTs of upper limb function or single treatment components.

PRIMARY OUTCOMES

measures of independence in activities of daily living (IADL) and motor function.

SECONDARY OUTCOMES

balance, gait velocity, and length of stay.

DATA COLLECTION AND ANALYSIS

Two independent authors selected studies according to pre-defined eligibility criteria, extracted data, and assessed the risk of bias in the included studies. We used GRADE to assess the certainty of evidence.

MAIN RESULTS

In this review update, we included 267 studies (21,838 participants). Studies were conducted in 36 countries, with half (133/267) in China. Generally, studies were heterogeneous, and often poorly reported. We judged only 14 studies in meta-analyses as at low risk of bias for all domains and, on average, we considered 33% of studies in analyses of primary outcomes at high risk of bias. Is physical rehabilitation more effective than no (or minimal) physical rehabilitation? Compared to no physical rehabilitation, physical rehabilitation may improve IADL (standardised mean difference (SMD) 1.32, 95% confidence interval (CI) 1.08 to 1.56; 52 studies, 5403 participants; low-certainty evidence) and motor function (SMD 1.01, 95% CI 0.80 to 1.22; 50 studies, 5669 participants; low-certainty evidence). There was evidence of long-term benefits for these outcomes. Physical rehabilitation may improve balance (MD 4.54, 95% CI 1.36 to 7.72; 9 studies, 452 participants; low-certainty evidence) and likely improves gait velocity (SMD 0.23, 95% CI 0.05 to 0.42; 18 studies, 1131 participants; moderate-certainty evidence), but with no evidence of long-term benefits. Is physical rehabilitation more effective than attention control? The evidence is very uncertain about the effects of physical rehabilitation, as compared to attention control, on IADL (SMD 0.91, 95% CI 0.06 to 1.75; 2 studies, 106 participants), motor function (SMD 0.13, 95% CI -0.13 to 0.38; 5 studies, 237 participants), and balance (MD 6.61, 95% CI -0.45 to 13.66; 4 studies, 240 participants). Physical rehabilitation likely improves gait speed when compared to attention control (SMD 0.34, 95% CI 0.14 to 0.54; 7 studies, 405 participants; moderate-certainty evidence). Does additional physical rehabilitation improve outcomes? Additional physical rehabilitation may improve IADL (SMD 1.26, 95% CI 0.82 to 1.71; 21 studies, 1972 participants; low-certainty evidence) and motor function (SMD 0.69, 95% CI 0.46 to 0.92; 22 studies, 1965 participants; low-certainty evidence). Very few studies assessed these outcomes at long-term follow-up. Additional physical rehabilitation may improve balance (MD 5.74, 95% CI 3.78 to 7.71; 15 studies, 795 participants; low-certainty evidence) and gait velocity (SMD 0.59, 95% CI 0.26 to 0.91; 19 studies, 1004 participants; low-certainty evidence). Very few studies assessed these outcomes at long-term follow-up. Is any one approach to physical rehabilitation more effective than any other approach? Compared to other approaches, those that focus on functional task training may improve IADL (SMD 0.58, 95% CI 0.29 to 0.87; 22 studies, 1535 participants; low-certainty evidence) and motor function (SMD 0.72, 95% CI 0.21 to 1.22; 20 studies, 1671 participants; very low-certainty evidence) but the evidence in the latter is very uncertain. The benefit was sustained long-term. The evidence is very uncertain about the effect of functional task training on balance (MD 2.16, 95% CI -0.24 to 4.55) and gait velocity (SMD 0.28, 95% CI -0.01 to 0.56). Compared to other approaches, neurophysiological approaches may be less effective than other approaches in improving IADL (SMD -0.34, 95% CI -0.63 to -0.06; 14 studies, 737 participants; low-certainty evidence), and there may be no difference in improving motor function (SMD -0.60, 95% CI -1.32 to 0.12; 13 studies, 663 participants; low-certainty evidence), balance (MD -0.60, 95% CI -5.90 to 6.03; 9 studies, 292 participants; low-certainty evidence), and gait velocity (SMD -0.17, 95% CI -0.62 to 0.27; 16 studies, 630 participants; very low-certainty evidence), but the evidence is very uncertain about the effect on gait velocity. For all comparisons, the evidence is very uncertain about the effects of physical rehabilitation on adverse events and length of hospital stay.

AUTHORS' CONCLUSIONS

Physical rehabilitation, using a mix of different treatment components, likely improves recovery of function and mobility after stroke. Additional physical rehabilitation, delivered as an adjunct to 'usual' rehabilitation, may provide added benefits. Physical rehabilitation approaches that focus on functional task training may be useful. Neurophysiological approaches to physical rehabilitation may be no different from, or less effective than, other physical rehabilitation approaches. Certainty in this evidence is limited due to substantial heterogeneity, with mainly small studies and important differences between study populations and interventions. We feel it is unlikely that any studies published since November 2022 would alter our conclusions. Given the size of this review, future updates warrant consensus discussion amongst stakeholders to ensure the most relevant questions are explored for optimal decision-making.

Stroke Rehabilitation: Synopsis of the 2024 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guidelines

DESCRIPTION

In July 2024, the U.S. Department of Veterans Affairs (VA) and U.S. Department of Defense (DOD) released a joint update of their 2019 clinical practice guideline (CPG) for the management of stroke rehabilitation. This synopsis is a condensed version of the 2024 CPG, highlighting the key aspects of the guideline development process and describing the major recommendations.

METHODS

The VA/DOD Evidence-Based Practice Work Group convened a joint VA/DOD guideline development work group (WG) that included clinical stakeholders and conformed to the Institute of Medicine's tenets for trustworthy CPGs. The guideline WG conducted a patient focus group, developed key questions, and systematically searched and evaluated the literature (English-language publications from 1 July 2018 to 2 May 2023). The GRADE (Grading of Recommendations Assessment, Development and Evaluation) system was used to evaluate the evidence. The WG developed 47 recommendations along with algorithms for stroke rehabilitation in the inpatient and outpatient settings. Stakeholders outside the WG reviewed the CPG before approval by the VA/DOD Evidence-Based Practice Work Group.

RECOMMENDATIONS

This synopsis summarizes where evidence is strongest to support guidelines in crucial areas relevant to primary care physicians: transition to community (case management, psychosocial or behavioral interventions); motor therapy (task-specific practice, mirror therapy, rhythmic auditory stimulation, electrical stimulation, botulinum toxin for spasticity); dysphagia, aphasia, and cognition (chin tuck against resistance, respiratory muscle strength training); and mental health (selective serotonin reuptake inhibitor use, psychotherapy, mindfulness-based therapies for treatment but not prevention of depression).

Influence of treadmill speed selection on gait parameters compared to overground walking in subacute rehabilitation patients

[Purpose] Treadmill-based interventions are widely utilized in rehabilitation due to their advantages of providing controlled environments and enabling individualized training. However, the differences between overground and treadmill walking during the subacute rehabilitation phase remain incompletely understood. This study aimed to compare gait parameters between treadmill walking at varying speeds and overground walking in a subacute rehabilitation setting. [Participants and Methods] A total of 42 inpatients with cerebrovascular and orthopedic conditions were recruited from a convalescent rehabilitation ward. Gait parameters were measured using the Gait Real-time Analysis Interactive Lab (GRAIL) system during comfortable overground walking and treadmill walking at various speeds, including self-selected comfortable speeds and speeds matched to overground walking. Walking speed, stride length, cadence, and step width were calculated without markers and compared across conditions. [Results] The comfortable treadmill walking speed was significantly lower than the overground walking speed (mean [standard deviation]: 0.85 [0.23] m/s vs. 1.20 [0.20] m/s). Stride length was significantly shorter during treadmill walking at comfortable speeds compared to overground walking (0.86 [0.22] m vs. 1.21 [0.18] m), whereas step width was significantly wider (0.17 [0.04] m vs. 0.13 [0.03] m). [Conclusion] Maintaining cadence at reduced treadmill speeds promotes comfortable endurance training in subacute rehabilitation patients.

Overground robotic exoskeleton vs conventional therapy in inpatient stroke rehabilitation: results from a pragmatic, multicentre implementation programme

BACKGROUND

Despite the reported efficacy of overground robotic exoskeleton (ORE) for rehabilitation of mobility post-stroke, its effectiveness in real-world practice is still debated. We analysed prospectively collected data from Improving Mobility Via Exoskeleton (IMOVE), a multicentre clinical implementation programme of ORE enrolling participants with various neurological conditions and were given options to choose between 12 sessions of ORE or conventional therapy (control).

METHODS

This is analysis of participants under IMOVE who fulfilled the following criteria (i) primary diagnosis was stroke (ischemic, hemorrhagic; first or recurrent), (ii) onset of stroke was within 9 months and (iii) the intervention was during inpatient stay. They should also fulfill the general IMOVE inclusion and exclusion criteria which were resembling general clinical and manufacturing criteria of ORE. Outcome measures included Functional Ambulatory Category (FAC), Rivermead Mobility Index (RMI), Functional Independence Measure (FIM) and Clinical Outcome Variable Scale (COVS), measured immediately before and after the 12 sessions of therapy, and mean distance walked per session.

RESULTS

Of 149 participants (105 OREs and 44 controls), both groups improved significantly in motor outcomes with no significant between-group differences. Participants with baseline FAC 1 had significantly greater improvement in motor sub-score of FIM (FIM-motor) compared to controls (mean difference 8.4, 95% CI 0.65-16.07, ηp2 = 0.136, p = 0.034). The mean distance walked per session for ORE group was almost three times that of control for those with baseline FAC 0 (121.5 [SD 31.1]m vs 35.0 [SD 41.0]m, 95% CI 62.2-110.9, d = 2.54 p < 0.001) and FAC 1 (145.8 [SD 31.6]m vs 52.2 [SD 42.5]m, 95% CI 61.8-125.2, d = 2.71, p < 0.001). The difference was not observed for FAC 2 to 3 (162.9 [SD 29.2]m vs 134.2 [SD 87.5]m, 95% CI -22.2 to 79.7, d = 0.41, p = 0.252).

CONCLUSION

In a pragmatic setting, use of ORE for gait training enabled patients with lower ambulatory capacity to walk longer distances during therapy sessions. Patients who required continuous assistance during ambulation (FAC 1) had significantly better gains in FIM-motor compared to conventional therapy, suggesting possible benefit of ORE for this group.

TRIAL REGISTRATION

The trial was registered with clinicaltrials.gov (NCT05659121) on April 14, 2022.

A Case with Left Hemiplegia after Cerebral Infarction with Improved Walking Ability Through Robot-assisted Gait Training Combined with Neuromuscular Electrical Stimulation for Foot Drop

Yamaguchi A, Kanazawa Y, Hirano S, Aoyagi Y. A Case with Left Hemiplegia after Cerebral Infarction with Improved Walking Ability Through Robot-assisted Gait Training Combined with Neuromuscular Electrical Stimulation for Foot Drop. Jpn J Compr Rehabil Sci 2024; 15: 88-93.

Background

Gait training-assist robots and neuromuscular electrical stimulation devices have been shown to be useful in gait training for patients with hemiplegia. However, no case reports have documented the combined use of a gait training-assist robot and a neuromuscular electrical stimulator for gait rehabilitation. In this study, we present the case of a patient with left hemiplegia who demonstrated remarkable improvement in walking ability after using a combination of a gait training-assist robot and a neuromuscular electrical stimulator for foot drop.

Case Presentation

A 60-year-old man developed severe left hemiplegia following a stroke in the right middle cerebral artery region. His lower limb motor function, as assessed by the Stroke Impairment Assessment Set (SIAS), was completely impaired (score of 0), and he was unable to walk by the 57th day post-onset. By the 66th day, his lower limb motor function remained unchanged (SIAS score of 0), and he frequently stumbled on his left foot at the start of the swing phase during gait training. As a result, robot-assisted gait training combined with neuromuscular electrical stimulation for foot drop was initiated. By the 88th day, his lower limb motor function improved to a score of 1 on the SIAS, and his Functional Independence Measure (FIM) walk item improved to a score of 4 with the use of an ankle-foot orthosis and a cane. On the 89th day, he transitioned to conventional therapy without the devices. By the 114th day, he was able to walk with a T-cane without the need for an orthosis.

Conclusion

The combination of a gait training-assist robot and a neuromuscular electrical stimulator for foot drop facilitated dorsiflexion of the ankle during the swing phase, allowed the patient to practice walking with minimal assistance. This promoted active patient-led walking and more efficient motor learning, ultimately leading to independent walking.

Artificial intelligence tools for engagement prediction in neuromotor disorder patients during rehabilitation

BACKGROUND

Robot-Assisted Gait Rehabilitation (RAGR) is an established clinical practice to encourage neuroplasticity in patients with neuromotor disorders. Nevertheless, tasks repetition imposed by robots may induce boredom, affecting clinical outcomes. Thus, quantitative assessment of engagement towards rehabilitation using physiological data and subjective evaluations is increasingly becoming vital. This study aimed at methodologically exploring the performance of artificial intelligence (AI) algorithms applied to structured datasets made of heart rate variability (HRV) and electrodermal activity (EDA) features to predict the level of patient engagement during RAGR.

METHODS

The study recruited 46 subjects (38 underage, 10.3 ± 4.0 years old; 8 adults, 43.0 ± 19.0 years old) with neuromotor impairments, who underwent 15 to 20 RAGR sessions with Lokomat. During 2 or 3 of these sessions, ad hoc questionnaires were administered to both patients and therapists to investigate their perception of a patient's engagement state. Their outcomes were used to build two engagement classification targets: self-perceived and therapist-perceived, both composed of three levels: "Underchallenged", "Minimally Challenged", and "Challenged". Patient's HRV and EDA physiological signals were processed from raw data collected with the Empatica E4 wristband, and 33 features were extracted from the conditioned signals. Performance outcomes of five different AI classifiers were compared for both classification targets. Nested k-fold cross-validation was used to deal with model selection and optimization. Finally, the effects on classifiers performance of three dataset preparation techniques, such as unimodal or bimodal approach, feature reduction, and data augmentation, were also tested.

RESULTS

The study found that combining HRV and EDA features into a comprehensive dataset improved the synergistic representation of engagement compared to unimodal datasets. Additionally, feature reduction did not yield any advantages, while data augmentation consistently enhanced classifiers performance. Support Vector Machine and Extreme Gradient Boosting models were found to be the most effective architectures for predicting self-perceived engagement and therapist-perceived engagement, with a macro-averaged F1 score of 95.6% and 95.4%, respectively.

CONCLUSION

The study displayed the effectiveness of psychophysiology-based AI models in predicting rehabilitation engagement, thus promoting their practical application for personalized care and improved clinical health outcomes.

Effectiveness of robot-assisted training in adults with Parkinson's disease: a systematic review and meta-analysis

AIM

This work aimed to update and summarize the existing evidence on the effectiveness of robot-assisted training (RAT) in adults with Parkinson's disease (PD).

METHODS

We conducted a systematic review with meta-analysis, reported following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PROSPERO CRD42022371124). Seven databases and two trial registries were searched for randomized-controlled trials (RCTs) addressing RAT alone or in addition to other treatments in adults with PD up to January 2024. Primary outcomes were disease-specific motor impairment, balance, mobility, freezing of gait, falls, number of people who fell at least once, and adverse events. Meta-analysis using a random-effects model was performed. Risk of bias (RoB) and certainty of the evidence for the primary outcomes were assessed using the Cochrane RoB Tool and the Grades of Recommendation Assessment, Development, and Evaluation (GRADE) approach, respectively.

RESULTS

Fifteen RCTs (629 randomized adults with PD) were included. Our results show that the evidence is very uncertain about the effectiveness of any kind of RAT, either focused on gait, balance or upper limb impairment, compared to any comparator (treadmill training, overground gait training, exercises without the exoskeleton, conventional physical therapy, balance training, and no treatment), mainly because of RoB, inconsistency in individual studies results, and very limited number (less than 200) of participants considered in each comparison.

CONCLUSION

In light of the aforementioned very low certainty evidence, clinical considerations should be drawn very carefully. High-quality studies are thus highly needed to investigate potential benefits, risks, and cost/benefit ratio of RAT in adults with PD.

Effectiveness of unilateral lower-limb exoskeleton robot on balance and gait recovery and neuroplasticity in patients with subacute stroke: a randomized controlled trial

BACKGROUND

Impaired balance and gait in stroke survivors are associated with decreased functional independence. This study aimed to evaluate the effectiveness of unilateral lower-limb exoskeleton robot-assisted overground gait training compared with conventional treatment and to explore the relationship between neuroplastic changes and motor function recovery in subacute stroke patients.

METHODS

In this randomized, single-blind clinical trial, 40 patients with subacute stroke were recruited and randomly assigned to either a robot-assisted training (RT) group or a conventional training (CT) group. All outcome measures were assessed at the enrollment baseline (T0), 2nd week (T1) and 4th week (T2) of the treatment. The primary outcome was the between-group difference in the change in the Berg balance scale (BBS) score from baseline to T2. The secondary measures included longitudinal changes in the Fugl-Meyer assessment of the lower limb (FMA-LE), modified Barthel index (mBI), functional ambulation category (FAC), and locomotion assessment with gait analysis. In addition, the cortical activation pattern related to robot-assisted training was measured before and after intervention via functional near-infrared spectroscopy.

RESULTS

A total of 30 patients with complete data were included in this study. Clinical outcomes improved after 4 weeks of training in both groups, with significantly better BBS (F = 6.341, p = 0.018, partial η2 = 0.185), FMA-LE (F = 5.979, p = 0.021, partial η2 = 0.176), FAC (F = 7.692, p = 0.010, partial η2 = 0.216), and mBI scores (F = 7.255, p = 0.042, partial η2 = 0.140) in the RT group than in the CT group. Both groups showed significant improvement in gait speed and stride cadence on the locomotion assessment. Only the RT group presented a significantly increased stride length (F = 4.913, p = 0.015, partial η2 = 0.267), support phase (F = 5.335, p = 0.011, partial η2 = 0.283), and toe-off angle (F = 3.829, p = 0.035, partial η2 = 0.228) on the affected side after the intervention. The RT group also showed increased neural activity response over the ipsilesional motor area and bilateral prefrontal cortex during robot-assisted weight-shift and gait training following 4 weeks of treatment.

CONCLUSIONS

Overground gait training with a unilateral exoskeleton robot showed improvements in balance and gait functions, resulting in better gait patterns and increased gait stability for stroke patients. The increased cortical response related to the ipsilesional motor areas and their related functional network is crucial in the rehabilitation of lower limb gait in post-stroke patients.

Effects of Assisted Walking Exercise in Chronic Dependent Ambulatory Stroke Survivors: A Mini-Review

Background

Assisted walking exercise programs are widely recommended in rehabilitation guidelines for stroke survivors. However, most evidence supporting these programs primarily focuses on ambulatory stroke survivors or those dependent ambulatory in acute and subacute stages. There is a notable gap in the application of walking exercise programs for chronic dependent ambulatory stroke survivors despite potential benefits in reducing sedentary behavior and improving rehabilitation outcomes. Thus, this literature review aims to summarize the existing evidence on the feasibility and efficacy of assisted walking exercise programs for chronic stroke survivors who are dependent ambulators.

Methods

Six major databases were searched for clinical trials related to assisted walking exercise and chronic dependent ambulatory stroke.

Results

Seven studies (evidence with low- to moderate-quality) involving 91 chronic dependent ambulatory stroke subjects are included in this review.

Conclusions

These studies indicated that assisted walking exercise is feasible to perform by chronic dependent ambulatory stroke survivors and can induce continued motor recovery and functional improvement. However, the mixed and limited evidence from existing research underscores the need for future high-quality randomized controlled trials with standardized designs and outcome measures to establish evidence-based walking programs for this population.

Therapeutic effects of powered exoskeletal robot-assisted gait training in inpatients in the early stage after stroke: a pilot case-controlled study

BACKGROUND

Robot-assisted rehabilitation is considered beneficial for functional recovery in patients with stroke, but the therapeutic effect remains inconclusive. The present study investigated the therapeutic effects of gait training assisted by a user-initiated powered exoskeletal robot (UIPER) in patients in the early stage after stroke. We also characterized patients' improvement by analyzing chronological changes in clinical measurements together with gait parameters obtained from internal sensors in the exoskeletal robot.

METHODS

In this pilot case-controlled study, 17 and 81 patients with stroke onset durations of < 3 months were included in the robot-assisted combined with conventional treatment (RT + CT) group and conventional treatment only (CT) group, respectively. The UIPER, which provides knee flexion and extension support and has hip and knee sensors, was applied to guide gait performance in the RT + CT group. The patients in the RT + CT group received robot-assisted gait training for 40 min/ session, 1 session a day, and 2-3 sessions a week (6 sessions in total). The primary outcome was the proportion of patients reaching the minimum clinically important difference (MCID) in the 5-meter walking speed (5MWS) assessment, and the secondary outcomes were the MCID for the six-minute walking test, the Berg Balance Scale, the Barthel Index, the Fugl-Meyer assessment, and the timed up and go test before, during, and after the interventions. Gait parameters of the hip and knee were evaluated at baseline, midterm, and final sessions.

RESULTS

Gait function improved in both groups after the intervention (both P < 0.05). The primary outcome showed that a greater proportion of patients reached the MCID for the 5MWS in the RT + CT group than in the CT group (70.6 vs. 43.2%, P = 0.040; [Formula: see text] = 0.208). Similarly, in terms of the secondary outcomes, more patients in the RT + CT group reached the MCID for the Barthel index as compared with the CT group (41.2 vs. 17.3%, P = 0.047, [Formula: see text] = 0.220). Gait analysis revealed improvements in gait in the RT + CT group, as indicated by increases in the perimeter and area of the hip-knee cyclogram, as well as the range of motion in the hip joint.

CONCLUSIONS

Gait training assisted by UIPER facilitates the recovery of walking speed and activities of daily living in patients with stroke, and these improvements may be related to improvements in gait parameters. Randomized controlled studies with larger sample sizes are needed to confirm these findings.

TRIAL REGISTRATION

This trial was approved by the Institutional Review Board of Chang Gung Medical Foundation (No. 202200822B0).

Effectiveness of Robotic Devices for Medical Rehabilitation: An Umbrella Review

Background/Objectives: Clinical trials have investigated the efficacy of rehabilitation robotics for various pathological conditions, but the overall impact on rehabilitation practice remains unclear. We comprehensively examined and analyzed systematic reviews (SRs) of randomized controlled trials (RCTs) investigating rehabilitative interventions with robotic devices. Methods: Four databases were searched using term combinations of keywords related to robotic devices, rehabilitation, and SRs. The SR meta-analyses were categorized into "convincing", "highly suggestive", "suggestive", "weak", or "non-significant" depending on evidence strength and validity. Results: Overall, 62 SRs of 341 RCTs involving 14,522 participants were identified. Stroke was most frequently reported (40 SRs), followed by spinal cord injury (eight SRs), multiple sclerosis (four SRs), cerebral palsy (four SRs), Parkinson's disease (three SRs), and neurological disease (any disease causing limited upper- and lower-limb functioning; three SRs). Furthermore, 38, 21, and 3 SRs focused on lower-limb devices, upper-limb devices, and both upper- and lower-limb devices, respectively. Quantitative synthesis of robotic intervention effects was performed by 51 of 62 SRs. Robot-assisted training was effective for various outcome measures per disease. Meta-analyses offering suggestive evidence were limited to studies on stroke. Upper-limb devices were effective for motor control and activities of daily living, and lower-limb devices for walking independence in stroke. Conclusions: Robotic devices are useful for improving impairments and disabilities in several diseases. Further high-quality SRs including RCTs with large sample sizes and meta-analyses of these RCTs, particularly on non-stroke-related diseases, are required. Further research should also ascertain which type of robotic device is the most effective for improving each specific impairment or disability.

Rest the brain to learn new gait patterns after stroke

BACKGROUND

The ability to relearn a lost skill is critical to motor recovery after a stroke. Previous studies indicate that stroke typically affects the processes underlying motor control and execution but not the learning of those skills. However, these studies could be confounded by the presence of significant motor impairments. Furthermore, prior research involving the upper extremity indicates that stroke survivors have an advantage in offline motor learning when compared with controls. However, this has not been examined using motor acuity tasks (i.e., tasks focusing on the quality of executed actions) that have direct functional relevance to rehabilitation.

OBJECTIVE

Investigate how stroke affects leg motor skill learning during walking in stroke survivors.

METHODS

Twenty-five participants (10 stroke; 15 controls) were recruited for this prospective, case-control study. Participants learned a novel foot-trajectory tracking task on two consecutive days while walking on a treadmill. The task necessitated greater hip and knee flexion during the swing phase of the gait. Online learning was measured by comparing tracking error at the beginning and end of each practice session, offline (rest-driven) learning was measured by comparing the end of the first practice session to the beginning of the second, and retention was measured by comparing the beginning of the first practice session to the beginning of the second. Online learning, offline learning, and retention were compared between the stroke survivors and uninjured controls.

RESULTS

Stroke survivors improved their tracking performance on the first day (p = 0.033); however, the amount of learning in stroke survivors was lower in comparison with the control group on both days (p ≤ 0.05). Interestingly, stroke survivors showed higher offline learning gains when compared with uninjured controls (p = 0.011).

CONCLUSIONS

Even stroke survivors with no perceivable motor impairments have difficulty acquiring new motor skills related to walking, which may be related to the underlying neural damage caused at the time of stroke. Furthermore, stroke survivors may require longer training with adequate rest to acquire new motor skills.

Effects of physical therapy modalities for motor function, functional recovery, and post-stroke complications in patients with severe stroke: a systematic review update

BACKGROUND

Physical therapy interventions play a crucial role in the daily care of patients recovering from severe stroke. However, the efficacy of these interventions and associated modalities, including duration, intensity, and frequency, have not been fully elucidated. In 2020, a systematic review reported the beneficial effects of physical therapy for patients with severe stroke but did not assess therapeutic modalities. We aim to update the current evidence on the effects of physical therapy interventions and their modalities in relation to the recovery phase in people with severe stroke in a hospital or inpatient rehabilitation facility.

METHODS

We searched CENTRAL, MEDLINE, Web of Science, and three other relevant databases between December 2018 and March 2021 and updated the search between April 2021 and March 2023.

CLINICALTRIALS

gov and ICTRP for searching trial registries helped to identify ongoing RCTs since 2023. We included individual and cluster randomized controlled trials in the English and German languages that compared physical therapy interventions to similar or other interventions, usual care, or no intervention in a hospital or rehabilitation inpatient setting. We screened the studies from this recent review for eligibility criteria, especially according to the setting. Critical appraisal was performed according to the Cochrane risk-of-bias tool 2.0. The data were synthesized narratively.

RESULTS

The update identified 15 new studies, cumulating in a total of 30 studies (n = 2545 participants) meeting the eligibility criteria. These studies reported 54 outcomes and 20 physical therapy interventions. Two studies included participants during the hyperacute phase, 4 during the acute phase,18 during the early subacute phase, and 3 in the late subacute phase. Three studies started in the chronic phase. Summarised evidence has revealed an uncertain effect of physical therapy on patient outcomes (with moderate to low-quality evidence). Most studies showed a high risk of bias and did not reach the optimal sample size. Little was stated about the standard care and their therapy modalities.

DISCUSSION

There is conflicting evidence for the effectiveness of physical therapy interventions in patients with severe stroke. There is a need for additional high-quality studies that also systematically report therapeutic modalities from a multidimensional perspective in motor stroke recovery. Due to the high risk of bias and the generally small sample size of the included studies, the generalizability of the findings to large and heterogeneous volumes of outcome data is limited.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42021244285.

Early robotic gait training after stroke (ERA Stroke): study protocol for a randomized clinical trial

BACKGROUND

Walking impairment after stroke is associated with substantial limitations in functional independence, quality of life, and long-term survival. People in the subacute phase after stroke who are unable to walk are most likely to benefit the greatest from use of overground robotic gait training (RGT). This study will provide preliminary evidence regarding the clinical use and efficacy of RGT during the subacute phase of stroke recovery as well as observational findings associated with the safety, tolerability, feasibility, and cost of delivering RGT during inpatient stroke rehabilitation.

METHODS

This prospectively registered randomized controlled trial will enroll 54 patients admitted to inpatient rehabilitation within six months of stroke. Admitted patients will be screened at admission to inpatient rehabilitation for eligibility. Consented patients will be randomized based on stroke severity to receive either RGT or usual care for 90 minutes per week of gait training intervention during inpatient rehabilitation length of stay. Patients will complete assessments on walking and health outcomes at admission and discharge from inpatient rehabilitation and at 1- and 3-month follow-up. Intent-to-treat and per protocol analysis will be performed to evaluate safety [rate of adverse events, visual analog scale, and treatment completion rate], walking function [gait speed via 10-Meter Walk Test, Functional Ambulation Category, gait endurance via 6-Minute Walk Test] and health outcomes [Modified Rankin Scale, Stroke Rehabilitation Assessment of Movement, Continuity Assessment Record and Evaluation Tool, 5 Times Sit-to-Stand Test, Berg Balance Scale, and Stroke Impact Scale-16], and cost-analysis.

DISCUSSION

This study will provide foundational evidence regarding the clinical use and efficacy of a RGT program during the subacute phase of stroke recovery with specific findings associated with the safety, tolerability, feasibility, and cost-analysis of delivering RGT during inpatient stroke rehabilitation.

TRIAL REGISTRATION

NCT06430632.

Robot-assisted gait training in stroke

Stroke is the second most common cause of mortality and disability worldwide. Most of the patients cannot regain their walking ability after a stroke. Impaired gait and mobility negatively affect the activities of daily living and quality of life of stroke survivors. Restoring gait and mobility are the most important targets of the rehabilitation approaches. Advances in computers and engineering have enabled robotics to be used in many areas of rehabilitation medicine. One of them is gait training. High-intensity, repetitive task training is crucial for neural plasticity and motor learning. Robot-assisted gait training may be a promising method leading to functional recovery in patients with stroke. In this review, the efficacy of robot-assisted gait training in stroke rehabilitation is discussed in light of current literature.

Robotics in Physical Rehabilitation: Systematic Review

As the global prevalence of motor disabilities continues to rise, there is a pressing need for advanced solutions in physical rehabilitation. This systematic review examines the progress and challenges of implementing robotic technologies in the motor rehabilitation of patients with physical disabilities. The integration of robotic technologies such as exoskeletons, assistive training devices, and brain-computer interface systems holds significant promise for enhancing functional recovery and patient autonomy. The review synthesizes findings from the most important studies, focusing on the clinical effectiveness of robotic interventions in comparison to traditional rehabilitation methods. The analysis reveals that robotic therapies can significantly improve motor function, strength, co-ordination, and dexterity. Robotic systems also support neuroplasticity, enabling patients to relearn lost motor skills through precise, controlled, and repetitive exercises. However, the adoption of these technologies is hindered by high costs, the need for specialized training, and limited accessibility. Key insights from the review highlight the necessity of personalizing robotic therapies to meet individual patient needs, alongside addressing technical, economic, social, and cultural barriers. The review also underscores the importance of continued research to optimize these technologies and develop effective implementation strategies. By overcoming these challenges, robotic technologies can revolutionize motor rehabilitation, improving quality of life and social integration for individuals with motor disabilities.

Effect of robotic exoskeleton training on lower limb function, activity and participation in stroke patients: a systematic review and meta-analysis of randomized controlled trials

Background

The current lower limb robotic exoskeleton training (LRET) for treating and managing stroke patients remains a huge challenge. Comprehensive ICF analysis and informative treatment options are needed. This review aims to analyze LRET' s efficacy for stroke patients, based on ICF, and explore the impact of intervention intensities, devices, and stroke phases.

Methods

We searched Web of Science, PubMed, and The Cochrane Library for RCTs on LRET for stroke patients. Two authors reviewed studies, extracted data, and assessed quality and bias. Standardized protocols were used. PEDro and ROB2 were employed for quality assessment. All analyses were done with RevMan 5.4.

Results

Thirty-four randomized controlled trials (1,166 participants) were included. For function, LRET significantly improved motor control (MD = 1.15, 95%CI = 0.29-2.01, p = 0.009, FMA-LE), and gait parameters (MD = 0.09, 95%CI = 0.03-0.16, p = 0.004, Instrumented Gait Velocity; MD = 0.06, 95%CI = 0.02-0.09, p = 0.002, Step length; MD = 4.48, 95%CI = 0.32-8.65, p = 0.04, Cadence) compared with conventional rehabilitation. For activity, LRET significantly improved walking independence (MD = 0.25, 95%CI = 0.02-0.48, p = 0.03, FAC), Gait Velocity (MD = 0.07, 95%CI = 0.03-0.11, p = 0.001) and balance (MD = 2.34, 95%CI = 0.21-4.47, p = 0.03, BBS). For participation, social participation (MD = 0.12, 95%CI = 0.03-0.21, p = 0.01, EQ-5D) was superior to conventional rehabilitation. Based on subgroup analyses, LRET improved motor control (MD = 1.37, 95%CI = 0.47-2.27, p = 0.003, FMA-LE), gait parameters (MD = 0.08, 95%CI = 0.02-0.14, p = 0.006, Step length), Gait Velocity (MD = 0.11, 95%CI = 0.03-0.19, p = 0.005) and activities of daily living (MD = 2.77, 95%CI = 1.37-4.16, p = 0.0001, BI) for the subacute patients, while no significant improvement for the chronic patients. For exoskeleton devices, treadmill-based exoskeletons showed significant superiority for balance (MD = 4.81, 95%CI = 3.10-6.52, p < 0.00001, BBS) and activities of daily living (MD = 2.67, 95%CI = 1.25-4.09, p = 0.00002, BI), while Over-ground exoskeletons was more effective for gait parameters (MD = 0.05, 95%CI = 0.02-0.08, p = 0.0009, Step length; MD = 6.60, 95%CI = 2.06-11.15, p = 0.004, Cadence) and walking independence (MD = 0.29, 95%CI = 0.14-0.44, p = 0.0002, FAC). Depending on the training regimen, better results may be achieved with daily training intensities of 45-60 min and weekly training intensities of 3 h or more.

Conclusion

These findings offer insights for healthcare professionals to make effective LRET choices based on stroke patient needs though uncertainties remain. Particularly, the assessment of ICF participation levels and the design of time-intensive training deserve further study.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO, Unique Identifier: CRD42024501750.

Implementation of a unilateral hip flexion exosuit to aid paretic limb advancement during inpatient gait retraining for individuals post-stroke: a feasibility study

BACKGROUND

During inpatient rehabilitation, physical therapists (PTs) often need to manually advance patients' limbs, adding physical burden to PTs and impacting gait retraining quality. Different electromechanical devices alleviate this burden by assisting a patient's limb advancement and supporting their body weight. However, they are less ideal for neuromuscular engagement when patients no longer need body weight support but continue to require assistance with limb advancement as they recover. The objective of this study was to determine the feasibility of using a hip flexion exosuit to aid paretic limb advancement during inpatient rehabilitation post-stroke.

METHODS

Fourteen individuals post-stroke received three to seven 1-hour walking sessions with the exosuit over one to two weeks in addition to standard care of inpatient rehabilitation. The exosuit assistance was either triggered by PTs or based on gait events detected by body-worn sensors. We evaluated clinical (distance, speed) and spatiotemporal (cadence, stride length, swing time symmetry) gait measures with and without exosuit assistance during 2-minute and 10-meter walk tests. Sessions were grouped by the assistance required from the PTs (limb advancement and balance support, balance support only, or none) without exosuit assistance.

RESULTS

PTs successfully operated the exosuit in 97% of sessions, of which 70% assistance timing was PT-triggered to accommodate atypical gait. Exosuit assistance eliminated the need for manual limb advancement from PTs. In sessions with participants requiring limb advancement and balance support, the average distance and cadence during 2-minute walk test increased with exosuit assistance by 2.2 ± 3.1 m and 3.4 ± 1.9 steps/min, respectively (p < 0.017). In sessions with participants requiring balance support only, the average speed during 10-meter walk test increased with exosuit by 0.07 ± 0.12 m/s (p = 0.042). Clinical and spatiotemporal measures of independent ambulators were similar with and without exosuit (p > 0.339).

CONCLUSIONS

We incorporated a unilateral hip flexion exosuit into inpatient stroke rehabilitation in individuals with varying levels of impairments. The exosuit assistance removed the burden of manual limb advancement from the PTs and resulted in improved gait measures in some conditions. Future work will understand how to optimize controller and assistance profiles for this population.

Treatment with robot-assisted gait trainer Walkbot along with physiotherapy vs. isolated physiotherapy in children and adolescents with cerebral palsy. Experimental study

BACKGROUND

Improving walking ability is a key objective in the treatment of children and adolescents with cerebral palsy, since it directly affects their activity and participation. In recent years, robotic technology has been implemented in gait treatment, which allows training of longer duration and repetition of the movement. To know the effectiveness of a treatment with the robotic-assisted gait trainer Walkbot combined with physiotherapy compared to the isolated physiotherapy treatment in children and adolescents with cerebral palsy, we carried out a clinical trial.

METHODS

23 participants, were divided into two groups: experimental and control. During 5 weeks, both groups received their physiotherapy sessions scheduled, in addition experimental group received 4 sessions per week of 40 min of robot. An evaluation of the participants was carried out before the intervention, at the end of the intervention, and at follow-up (two months after the end of the intervention). Gait was assessed with the Gross Motor Function Measure-88 dimensions D and E, strength was measured with a hydraulic dynamometer, and range of motion was assessed using the goniometer. A mixed ANOVA was performed when the assumptions of normality and homoscedasticity were met, and a robust mixed ANOVA was performed when these assumptions were not met. Statistical significance was stipulated at p < 0.05. For the effect size, η2 was calculated.

RESULTS

Significant differences were found regarding the time x group interaction in the Gross Motor Function Measure-88 in dimension D [η2 = 0.016], in the flexion strength of the left [η2 = 0.128] and right [η2 = 0.142] hips, in the extension strength of the right hip [η2 = 0.035], in the abduction strength of the left hip [η2 = 0.179] and right [η2 = 0.196], in the flexion strength of the left knee [η2 = 0.222] and right [η2 = 0.147], and in the range of motion of left [η2 = 0.071] and right [η2 = 0.053] knee flexion.

CONCLUSIONS

Compared to treatments without walking robot, physiotherapy treatment including Walkbot improves standing, muscle strength, and knee range of motion in children and adolescents with cerebral palsy.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT04329793. First posted: April 1, 2020.

Modeling Neuromotor Adaptation to Pulsed Torque Assistance During Walking

Multiple mechanisms of motor learning contribute to the response of individuals to robot-aided gait training, including error-based learning and use-dependent learning. Previous models described either of these mechanisms, but not both, and their relevance to gait training is unknown. In this paper, we establish the validity of existing models to describe the response of healthy individuals to robot-aided training of propulsion via a robotic exoskeleton, and propose a new model that accounts for both use-dependent and error-based learning. We formulated five state-space models to describe the stride-by-stride evolution of metrics of propulsion mechanics during and after robot-assisted training, applied by a hip/knee robotic exoskeleton for 200 consecutive strides. The five models included a single-state, a two-state, a two-state fast and slow, a use-dependent learning (UDL), and a newly-developed modified UDL model, requiring 4, 9, 5, 3, and 4 parameters, respectively. The coefficient of determination (R 2) and Akaike information criterion (AIC) values were calculated to quantify the goodness of fit of each model. Model fit was conducted both at the group and at the individual participant level. At the group level, the modified UDL model shows the best goodness-of-fit compared to other models in AIC values in 15/16 conditions. At the participant level, both the modified UDL model and the two-state model have significantly better goodness-of-fit compared to the other models. In summary, the modified UDL model is a simple 4-parameter model that achieves similar goodness-of-fit compared to a two-state model requiring 9 parameters. As such, the modified UDL model is a promising model to describe the effects of robot-aided gait training on propulsion mechanics.

Efficacy of Daoyin combined with lower limb robot as a comprehensive rehabilitation intervention for stroke patients: a randomized controlled trial

OBJECTIVE

To assess the effectiveness of a comprehensive rehabilitation approach combining Traditional Chinese Medicine Daoyin with lower limb robotics during the recovery phase of stroke patients.

METHODS

Stroke patients meeting the specified criteria were randomly assigned to one of four groups using a random number table: Control group, Daoyin group, lower limb robot group (LLR group), and Daoyin and lower limb robot group (DLLR group). Each group received distinct treatments based on conventional rehabilitation training. The treatment duration spanned two weeks with two days of rest per week. Pre- and post-intervention assessments included various scales: Fugl-Meyer Assessment (FMA), Berg balance scale (BBS), Barthel index (BI), Fatigue Scale-14 (FS-14), Pittsburgh sleep quality index (PSQI), Hamilton Anxiety Scale (HAMA), and Hamilton Depression Scale (HAMD).

RESULTS

Statistically significant differences were observed in the lower limb function measured by FAM between the Control group (15 ± 5) and the DLLR group (18 ± 5) (P = 0.049). In the Barthel index, a statistically significant difference was noted between the Control group (54 ± 18) and the DLLR group (64 ± 11) (P = 0.041). Additionally, significant differences were found in the Berg balance scale between the Control group (21 ± 10) and the DLLR group (27 ± 8) (P = 0.024), as well as between the Control group (21 ± 10) and the LLR group (26 ± 10) (P = 0.048).

CONCLUSION

The findings of this study suggest that the combined use of Daoyin and robotics not only enhances motor function in stroke patients but also has a positive impact on fatigue, sleep quality, and mood. This approach may offer a more effective rehabilitation strategy for stroke patients.

Robotic exoskeleton-assisted walking rehabilitation for stroke patients: a bibliometric and visual analysis

Objective

This study aimed to conduct a bibliometric analysis of the literature on exoskeleton robot assisted walking rehabilitation for stroke patients in the Web of Science Core Collection over the past decade.

Method

Retrieved literature on exoskeleton robot assisted gait training for stroke hemiplegic patients from the Web of Science Core Collection from 1 January 2014 to 31 January 2024. The search method was topic search, and the types of documents were "article, meeting abstract, review article, early access." CiteSpace was used to analyze the search results from countries, institutions, keywords, cited references and cited authors.

Result

A total of 1,349 articles were retrieved, and 1,034 were ultimately included for visualization analysis. The annual publication volume showed an upward trend, with countries, institutions, and authors from Europe and America in a leading position. The core literature was also published by authors from European and American countries. The keywords were divided into 8 clusters: # 0 soft robotic exit, # 1 robot assisted gain training, # 2 multiple scales, # 3 magnetic rheological brake, # 4 test retest reliability, # 5 electromechanical assisted training, # 6 cerebra salary, and # 7 slow gain. The early research direction focused on the development of exoskeleton robots, verifying their reliability and feasibility. Later, the focus was on the combination of exoskeleton robot with machine learning and other technologies, rehabilitation costs, and patient quality of life.

Conclusion

This study provides a visual display of the research status, development trends, and research hotspots, which helps researchers in this field to grasp the research hotspots and choose future research directions.

Effects of robot-assisted gait training using the Welwalk on gait independence for individuals with hemiparetic stroke: an assessor-blinded, multicenter randomized controlled trial

BACKGROUND

Gait disorder remains a major challenge for individuals with stroke, affecting their quality of life and increasing the risk of secondary complications. Robot-assisted gait training (RAGT) has emerged as a promising approach for improving gait independence in individuals with stroke. This study aimed to evaluate the effect of RAGT in individuals with subacute hemiparetic stroke using a one-leg assisted gait robot called Welwalk WW-1000.

METHODS

An assessor-blinded, multicenter randomized controlled trial was conducted in the convalescent rehabilitation wards of eight hospitals in Japan. Participants with first-ever hemiparetic stroke who could not walk at pre-intervention assessment were randomized to either the Welwalk group, which underwent RAGT with conventional physical therapy, or the control group, which underwent conventional physical therapy alone. Both groups received 80 min of physical therapy per day, 7 days per week, while the Welwalk group received 40 min of RAGT per day, 6 days per week, as part of their physical therapy. The primary outcome was gait independence, as assessed using the Functional Independence Measure Walk Score.

RESULTS

A total of 91 participants were enrolled, 85 of whom completed the intervention. As a result, 91 participants, as a full analysis set, and 85, as a per-protocol set, were analyzed. The primary outcome, the cumulative incidence of gait-independent events, was not significantly different between the groups. Subgroup analysis revealed that the interaction between the intervention group and stroke type did not yield significant differences in either the full analysis or per-protocol set. However, although not statistically significant, a discernible trend toward improvement with Welwalk was observed in cases of cerebral infarction for the full analysis and per-protocol sets (HR 4.167 [95%CI 0.914-18.995], p = 0.065, HR 4.443 [95%CI 0.973-20.279], p = 0.054, respectively).

CONCLUSIONS

The combination of RAGT using Welwalk and conventional physical therapy was not significantly more effective than conventional physical therapy alone in promoting gait independence in individuals with subacute hemiparetic stroke, although a trend toward earlier gait independence was observed in individuals with cerebral infarction.

TRIAL REGISTRATION

This study was registered with the Japan Registry of Clinical Trials ( https://jrct.niph.go.jp ; jRCT 042180078) on March 3, 2019.

Behavior Change Approaches in Digital Technology-Based Physical Rehabilitation Interventions Following Stroke: Scoping Review

BACKGROUND

Digital health technologies (DHTs) are increasingly used in physical stroke rehabilitation to support individuals in successfully engaging with the frequent, intensive, and lengthy activities required to optimize recovery. Despite this, little is known about behavior change within these interventions.

OBJECTIVE

This scoping review aimed to identify if and how behavior change approaches (ie, theories, models, frameworks, and techniques to influence behavior) are incorporated within physical stroke rehabilitation interventions that include a DHT.

METHODS

Databases (Embase, MEDLINE, PsycINFO, CINAHL, Cochrane Library, and AMED) were searched using keywords relating to behavior change, DHT, physical rehabilitation, and stroke. The results were independently screened by 2 reviewers. Sources were included if they reported a completed primary research study in which a behavior change approach could be identified within a physical stroke rehabilitation intervention that included a DHT. Data, including the study design, DHT used, and behavior change approaches, were charted. Specific behavior change techniques were coded to the behavior change technique taxonomy version 1 (BCTTv1).

RESULTS

From a total of 1973 identified sources, 103 (5%) studies were included for data charting. The most common reason for exclusion at full-text screening was the absence of an explicit approach to behavior change (165/245, 67%). Almost half (45/103, 44%) of the included studies were described as pilot or feasibility studies. Virtual reality was the most frequently identified DHT type (58/103, 56%), and almost two-thirds (65/103, 63%) of studies focused on upper limb rehabilitation. Only a limited number of studies (18/103, 17%) included a theory, model, or framework for behavior change. The most frequently used BCTTv1 clusters were feedback and monitoring (88/103, 85%), reward and threat (56/103, 54%), goals and planning (33/103, 32%), and shaping knowledge (33/103, 32%). Relationships between feedback and monitoring and reward and threat were identified using a relationship map, with prominent use of both of these clusters in interventions that included virtual reality.

CONCLUSIONS

Despite an assumption that DHTs can promote engagement in rehabilitation, this scoping review demonstrates that very few studies of physical stroke rehabilitation that include a DHT overtly used any form of behavior change approach. From those studies that did consider behavior change, most did not report a robust underpinning theory. Future development and research need to explicitly articulate how including DHTs within an intervention may support the behavior change required for optimal engagement in physical rehabilitation following stroke, as well as establish their effectiveness. This understanding is likely to support the realization of the transformative potential of DHTs in stroke rehabilitation.

Effects of robotic-assisted early mobilization versus conventional mobilization in intensive care unit patients: prospective interventional cohort study with retrospective control group analysis

BACKGROUND

Approximately one in three survivors of critical illness suffers from intensive-care-unit-acquired weakness, which increases mortality and impairs quality of life. By counteracting immobilization, a known risk factor, active mobilization may mitigate its negative effects on patients. In this single-center trial, the effect of robotic-assisted early mobilization in the intensive care unit (ICU) on patients' outcomes was investigated.

METHODS

We enrolled 16 adults scheduled for lung transplantation to receive 20 min of robotic-assisted mobilization and verticalization twice daily during their first week in the ICU (intervention group: IG). A control group (CG) of 13 conventionally mobilized patients after lung transplantation was recruited retrospectively. Outcome measures included the duration of mechanical ventilation, length of ICU stay, muscle parameters evaluated by ultrasound, and quality of life after three months.

RESULTS

During the first week in the ICU, the intervention group received a median of 6 (interquartile range 3-8) robotic-assisted sessions of early mobilization and verticalization. There were no statistically significant differences in the duration of mechanical ventilation (IG: median 126 vs. CG: 78 h), length of ICU stay, muscle parameters evaluated by ultrasound, and quality of life after three months between the IG and CG.

CONCLUSION

In this study, robotic-assisted mobilization was successfully implemented in the ICU setting. No significant differences in patients' outcomes were observed between conventional and robotic-assisted mobilization. However, randomized and larger studies are necessary to validate the adequacy of robotic mobilization in other cohorts.

TRIAL REGISTRATION

This single-center interventional trial was registered in clinicaltrials.gov as NCT05071248 on 27/08/2021.

Robot-assisted support combined with electrical stimulation for the lower extremity in stroke patients: a systematic review

Objective. The incidence of stroke rising, leading to an increased demand for rehabilitation services. Literature has consistently shown that early and intensive rehabilitation is beneficial for stroke patients. Robot-assisted devices have been extensively studied in this context, as they have the potential to increase the frequency of therapy sessions and thereby the intensity. Robot-assisted systems can be combined with electrical stimulation (ES) to further enhance muscle activation and patient compliance. The objective of this study was to review the effectiveness of ES combined with all types of robot-assisted technology for lower extremity rehabilitation in stroke patients.Approach. A thorough search of peer-reviewed articles was conducted. The quality of the included studies was assessed using a modified version of the Downs and Black checklist. Relevant information regarding the interventions, devices, study populations, and more was extracted from the selected articles.Main results. A total of 26 articles were included in the review, with 23 of them scoring at least fair on the methodological quality. The analyzed devices could be categorized into two main groups: cycling combined with ES and robots combined with ES. Overall, all the studies demonstrated improvements in body function and structure, as well as activity level, as per the International Classification of Functioning, Disability, and Health model. Half of the studies in this review showed superiority of training with the combination of robot and ES over robot training alone or over conventional treatment.Significance. The combination of robot-assisted technology with ES is gaining increasing interest in stroke rehabilitation. However, the studies identified in this review present challenges in terms of comparability due to variations in outcome measures and intervention protocols. Future research should focus on actively involving and engaging patients in executing movements and strive for standardization in outcome values and intervention protocols.

A comparison of the immediate effects of the Andago over ground body weight support trainer versus over ground walking on selected gait parameters in a post-acute rehabilitation population

BACKGROUND

The Andago is an electromechanical gait trainer providing dynamic body weight support while simultaneously enabling over ground walking. The aim of this study was to compare the effects of the Andago with over ground walking on selected gait parameters, during a single gait reeducation session in a post-acute rehabilitation population.

METHODS

Twenty-seven participants (mean age 78 yrs. (SD = 9.2), female 55.6% (n = 15)) undergoing rehabilitation for neurological (51.8%, n = 14), orthopedic (33.3%, n = 9), and medical conditions (14.8%, n = 4) completed the study. This was a single group, cross sectional, repeated measures study. Participants completed a 10-meter walk test (10MWT) and a 20-minute gait reeducation session under two conditions: i) harnessed in the Andago with body weight support or ii) using their normal walking pattern. Walking speed, steps taken, distance walked, rest breaks, Borg ratings of perceived exertion, and fear of falling were compared over both conditions.

RESULTS

Walking speed was significantly slower with the Andago (10MWT mean difference 0.12 (95% CI 0.03-0.20), eta squared 0.24, p = .008; 20-min gait mean difference 0.04 (95% CI 0.00-0.09), eta squared 0.15, p = .049). During the 20-minute gait reeducation session, step count, distance walked, and duration of walking was similar over both conditions, however participants recorded less rest breaks and fear of falling at minutes 10 and 20 in favor of the Andago.

CONCLUSION

Gait parameters measured during a single gait reeducation session in the Andago, in a mixed cohort of predominately older rehabilitation patients, appear comparable to conventional over ground training, other than walking speed which was reduced.

Therapists and patients perceptions of a mixed reality system designed to improve trunk control and upper extremity function

A prototype system aimed at improving arm function and trunk control after stroke has been developed that combines mixed-reality (MR) feedback with a mobile seat system (Holoreach). The purpose of this study was to assess the usability of Holoreach in a rehabilitation setting from both the patient and therapist perspective. Ten therapists (eight physiotherapists and two occupational therapists) used the device in their regular therapy programs for fifteen stroke patients with trunk control issues. Each patient received four individual therapy sessions with the device performed under the supervision of the therapist. Therapists and patients kept therapy diaries and used customized questionnaires. At the end of the study two focus groups were conducted to further assess usability. Generally, the prototype system is suitable for training trunk and arm control. The therapists expressed overall positive views on the impact of Holoreach. They characterized it as new, motivating, fresh, joyful, interesting, and exciting. All therapists and 80% of the patients agreed with the statement that training with Holoreach is beneficial for rehabilitation. Nonetheless, improvements are required in the hardware and software, and design. The prototype system contributes at various levels to the rapidly evolving advances in neurorehabilitation, particularly regarding the practical aspect of exercise delivery.

Differences in kinetic factors affecting gait speed between lesion sides in patients with stroke

The differences in kinetic mechanisms of decreased gait speed across brain lesion sides have not been elucidated, including the arrangement of motor modules reflected by kinetic interjoint coordination. The purpose of this study was to elucidate the differences in the kinetic factors of slow gait speed in patients with stroke on the lesion sides. A three-dimensional motion analysis system was employed to assess joint moment in the lower limb and representative gait parameters in 32 patients with right hemisphere brain damage (RHD) and 38 patients with left hemisphere brain damage (LHD) following stroke as well as 20 healthy controls. Motor module composition and timing were determined using principal component analysis based on the three joint moments in the lower limb in the stance phase, which were the variances accounted for principal components (PCs) and the peak timing in the time series of PCs. A stepwise multiple linear regression analysis was performed to identify the most significant joint moment and PC-associated parameter in explaining gait speed. A negligible difference was observed in age, weight, height, and gait speed among patients with RHD and LHD and controls. The following factors contributed to gait speed: in patients with RHD, larger ankle plantarflexion moment on the paretic (p = 0.001) and nonparetic (p = 0.002) sides and ankle dorsiflexion moment on the nonparetic side (p = 0.004); in patients with LHD, larger ankle plantarflexion moment (p < 0.001) and delayed peak timing of the first PC (p = 0.012) on the paretic side as well as ankle dorsiflexion moment on the nonparetic side (p < 0.001); in the controls, delayed peak timing of the first PC (p = 0.002) on the right side and larger ankle dorsiflexion moment (p = 0.001) as well as larger hip flexion moment on the left side (p = 0.023). The findings suggest that the kinetic mechanisms of gait speed may differ among patients with RHD following patients with stroke with LHD, and controls.

Simultaneous high-definition transcranial direct current stimulation and robot-assisted gait training in stroke patients

This study investigates whether simultaneous high-definition transcranial direct current stimulation (HD-tDCS) enhances the effects of robot-assisted gait training in stroke patients. Twenty-four participants were randomly allocated to either the robot-assisted gait training with real HD-tDCS group (real HD-tDCS group) or robot-assisted gait training with sham HD-tDCS group (sham HD-tDCS group). Over four weeks, both groups completed 10 sessions. The 10 Meter Walk Test, Timed Up and Go, Functional Ambulation Category, Functional Reach Test, Berg Balance Scale, Dynamic Gait Index, Fugl-Meyer Assessment, and Korean version of the Modified Barthel Index were conducted before, immediately after, and one month after the intervention. The real HD-tDCS group showed significant improvements in the 10 Meter Walk Test, Timed Up and Go, Functional Reach Test, and Berg Balance Scale immediately and one month after the intervention, compared with before the intervention. Significant improvements in the Dynamic Gait Index and Fugl-Meyer Assessment were also observed immediately after the intervention. The sham HD-tDCS group showed no significant improvements in any of the tests. Application of HD-tDCS during robot-assisted gait training has a positive effect on gait and physical function in chronic stroke patients, ensuring long-term training effects. Our results suggest the effectiveness of HD-tDCS as a complementary tool to enhance robotic gait rehabilitation therapy in chronic stroke patients.

Body-weight support gait training in neurological intensive care: safety, feasibility, and delays before walking with or without suspension

BACKGROUND

Early Mobilization in Intensive Care Units (ICUs) enhances patients' evolution, but has been rarely studied in neurological ICUs. The aim of this study was to assess gait training with body-weight support (BWS) in neuroICU, and to report on its safety, feasibility and on delays before walking with and without BWS.

METHODS

This study was an observational one-year single-center study. Inclusion criteria were adults with a neurological injury requiring mechanical ventilation. Exclusion criteria were early death or ICU transfer. After weaning from ventilation, patients were screened for indications of BWS walking using predefined criteria.

RESULTS

Patients' conditions were mostly brain injuries: 32% subarachnoid hemorrhages, 42% focal strokes, and 12% traumatic brain injuries. Out of 272 admissions, 136 patients were excluded, 78 were eligible, and 33 performed BWS walking. Among non-eligible patients, 36 walked unsuspended upon ventilation weaning, 17 presented too severe impairments. Among the 45 eligible patients who did not receive BWS training, main reasons were workload and weekends (31%), medical barriers (29%), and early ICU discharge (22%). 78 BWS sessions were performed on the 33 beneficiaries (median sessions per patient 2, max 10). Pre-session, most patients had inadequate response to pain, orders, or simple orientation questions. Sitting without support was impossible for 74%. Most pre-post changes in hemodynamic, respiratory, and pain parameters were small, and recovered spontaneously after the session. Eight sessions were interrupted; reasons were pain, fatigue or major imbalance (4), syncope (1), occurrence of stool (2), and battery failure (1). None of these adverse events required medical intervention, patients recovered upon session interruption. Median session duration was 31 min, patients walked on median 17 m. First BWS session occurred on median 3 days after ventilation weaning, and 11 days before patients were able to walk unsuspended.

CONCLUSIONS

Verticalization and walking using a suspension device in patients in neuroICU allows early gait training, despite challenging neurological impairments. It is safe and generally well tolerated.

TRIAL REGISTRATION

ClinicalTrials database (ID: NCT04300491).

Unraveling Transformative Effects after tDCS and BCI Intervention in Chronic Post-Stroke Patient Rehabilitation-An Alternative Treatment Design Study

Stroke is a debilitating clinical condition resulting from a brain infarction or hemorrhage that poses significant challenges for motor function restoration. Previous studies have shown the potential of applying transcranial direct current stimulation (tDCS) to improve neuroplasticity in patients with neurological diseases or disorders. By modulating the cortical excitability, tDCS can enhance the effects of conventional therapies. While upper-limb recovery has been extensively studied, research on lower limbs is still limited, despite their important role in locomotion, independence, and good quality of life. As the life and social costs due to neuromuscular disability are significant, the relatively low cost, safety, and portability of tDCS devices, combined with low-cost robotic systems, can optimize therapy and reduce rehabilitation costs, increasing access to cutting-edge technologies for neuromuscular rehabilitation. This study explores a novel approach by utilizing the following processes in sequence: tDCS, a motor imagery (MI)-based brain-computer interface (BCI) with virtual reality (VR), and a motorized pedal end-effector. These are applied to enhance the brain plasticity and accelerate the motor recovery of post-stroke patients. The results are particularly relevant for post-stroke patients with severe lower-limb impairments, as the system proposed here provides motor training in a real-time closed-loop design, promoting cortical excitability around the foot area (Cz) while the patient directly commands with his/her brain signals the motorized pedal. This strategy has the potential to significantly improve rehabilitation outcomes. The study design follows an alternating treatment design (ATD), which involves a double-blind approach to measure improvements in both physical function and brain activity in post-stroke patients. The results indicate positive trends in the motor function, coordination, and speed of the affected limb, as well as sensory improvements. The analysis of event-related desynchronization (ERD) from EEG signals reveals significant modulations in Mu, low beta, and high beta rhythms. Although this study does not provide conclusive evidence for the superiority of adjuvant mental practice training over conventional therapy alone, it highlights the need for larger-scale investigations.

The Effect of Robot-Assisted Training on Arm Function, Walking, Balance, and Activities of Daily Living After Stroke: A Systematic Review and Meta-Analysis

This meta-analysis aimed to compare the effects of robot-assisted training (RAT) with those of conventional therapy (CT), considering the potential sources of heterogeneity in the previous studies. We searched three international electronic databases (MEDLINE, Embase, and the Cochrane Library) to identify relevant studies. Risk of bias assessment was performed using the Cochrane's Risk of Bias 1.0 tool. The certainty of the evidence was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluations method. The meta-analyses for each outcome of the respective domains were performed using 24 randomized controlled trials (RCTs) on robot-assisted arm training (RAAT) for arm function, 7 RCTs on RAAT for activities of daily living (ADL), 12 RCTs on robot-assisted gait training (RAGT) for balance, 6 RCTs on RAGT for walking, and 7 RCTs on RAGT for ADL. The random-effects model for the meta-analysis revealed that RAAT has significant superiority over CT in improving arm function, and ADL. We also showed that RAGT has significant superiority over CT in improving balance. Our study provides high-level evidence for the superiority of RAT over CT in terms of functional recovery after stroke. Therefore, physicians should consider RAT as a therapeutic option for facilitating functional recovery after stroke.

Assessing walking ability using a robotic gait trainer: opportunities and limitations of assist-as-needed control in spinal cord injury

BACKGROUND

Walking impairments are a common consequence of neurological disorders and are assessed with clinical scores that suffer from several limitations. Robot-assisted locomotor training is becoming an established clinical practice. Besides training, these devices could be used for assessing walking ability in a controlled environment. Here, we propose an adaptive assist-as-needed (AAN) control for a treadmill-based robotic exoskeleton, the Lokomat, that reduces the support of the device (body weight support and impedance of the robotic joints) based on the ability of the patient to follow a gait pattern displayed on screen. We hypothesize that the converged values of robotic support provide valid and reliable information about individuals' walking ability.

METHODS

Fifteen participants with spinal cord injury and twelve controls used the AAN software in the Lokomat twice within a week and were assessed using clinical scores (10MWT, TUG). We used a regression method to identify the robotic measure that could provide the most relevant information about walking ability and determined the test-retest reliability. We also checked whether this result could be extrapolated to non-ambulatory and to unimpaired subjects.

RESULTS

The AAN controller could be used in patients with different injury severity levels. A linear model based on one variable (robotic knee stiffness at terminal swing) could explain 74% of the variance in the 10MWT and 61% in the TUG in ambulatory patients and showed good relative reliability but poor absolute reliability. Adding the variable 'maximum hip flexor torque' to the model increased the explained variance above 85%. This did not extend to non-ambulatory nor to able-bodied individuals, where variables related to stance phase and to push-off phase seem more relevant.

CONCLUSIONS

The novel AAN software for the Lokomat can be used to quantify the support required by a patient while performing robotic gait training. The adaptive software might enable more challenging training conditions tuned to the ability of the individuals. While the current implementation is not ready for assessment in clinical practice, we could demonstrate that this approach is safe, and it could be integrated as assist-as-needed training, rather than as assessment.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02425332.

Cost-effectiveness analysis of robot-assisted gait training in patients with bilateral spastic cerebral palsy

BACKGROUND

To date, there have been no published studies evaluating the cost-effectiveness of robot-assisted gait training (RAGT) in adolescent and adult patients with cerebral palsy (CP). The study´s aim was to analyse the cost-effectiveness of RAGT versus conventional kinesiotherapy (CON) from the health care provider's perspective.

METHODS

We expressed the cost-effectiveness of RAGT in the Lokomat® system after analysing the costs and effects of RAGT and conventional therapy through the Incremental Cost-Effectiveness Ratio (ICER) based on a bicentric randomized controlled study, in which we demonstrated that the intensive RAGT regimen is more effective than conventional therapy in terms of improvements in gross motor functions in adolescent and adult patients with bilateral spastic CP.

RESULTS

According to the calculated ICER ratio for Lokomat®, an additional improvement per unit of effect (1% in GMFM), compared to conventional therapy, results in an average cost increase of EUR70.38 per patient in a therapeutic block consisting of 20 TUs (Therapeutic Units).

CONCLUSION

However, from the comprehensive analysis of the results and evaluation of the long-term effects, it follows that RAGT applied in adolescent and adult patients with bilateral spastic CP is not only more effective in terms of evaluation of monitored clinical parameters, but in the long term it is also more cost-effective compared to conventional therapy.

1D-Convolutional Neural Networks can Quantify Therapy Content of Children and Adolescents Walking in a Robot-Assisted Gait Trainer

Therapy content, consisting of device parameter settings and therapy instructions, is crucial for an effective robot-assisted gait therapy program. Settings and instructions depend on the therapy goals of the individual patient. While device parameters can be recorded by the robot, therapeutic instructions and associated patient responses are currently difficult to capture. This limits the transferability of successful therapeutic approaches between clinics. Here, we propose that 1D-convolutional neural networks can be used to relate patient behavior during individual steps to the instructions given as a surrogate for the patient's intent. Our model takes the surface electromyography patterns of two leg muscles as input and predicts the given instruction as output. We tested this approach with data from 20 healthy children walking in a robot-assisted gait trainer with 5 different instructions. Our model performs well, with a classification accuracy of almost 90%, when the instruction targets specific aspects of gait, such as step length. This shows that 1D-convolutional neural networks are a viable tool for quantifying therapy content. Thus, they could help compare therapy approaches and identify effective strategies.

End-User Perspectives of the Importance of Rehabilitation Technologies and Related Values for Implementation

Despite the increased availability of rehabilitation technologies (such as robotics) and evidence to support their use, their adoption is still limited in practice. To begin to address this issue, we sought to better understand the perspectives of end-users regarding the implementation of rehabilitation technologies through an online survey. Fifty unique responses across Client (e.g., people with disability and carers), Allied Health (e.g., occupational and physical therapists, podiatrists, psychologists, dieticians, audiologists, exercise physiologists), and Medical (i.e., physicians and nurses) groups were analyzed. Respondents considered rehabilitation technologies to be important (median across groups of 9 out of 10). Across groups, value statements related to the implementation of rehabilitation technologies ranked from most to least important related to: benefits of technology to its intended end-user with disability, practical use of technologies, the technologies themselves (e.g., innovative, established, stand-alone), and their impact on health professionals or the health system as a whole. There were similarities and differences in ranking within and across end-user groups. The prioritization of statements indicates where development efforts can be focused to address end-user goals, and disparity in results across groups supports rich stakeholder engagement during rehabilitation technology development.

Combined Ankle Robot Training and Robot-assisted Gait Training Improved the Gait Pattern of a Patient with Chronic Traumatic Brain Injury

Background

: Walking disability caused by central nervous system injury often lingers. In the chronic phase, there is great need to improve walking speed and gait, even for patients who walk independently. Robot-assisted gait training (RAGT) has been widely used, but few studies have focused on improving gait patterns, and its effectiveness for motor function has been limited. This report describes the combination of "RAGT to learn the gait pattern" and "ankle robot training to improve motor function" in a patient with chronic stage brain injury.

Case

: A 34-year-old woman suffered a traumatic brain injury 5 years ago. She had residual right hemiplegia [Fugl-Meyer Assessment-Lower Extremity (FMA-LE): 18 points] and mild sensory impairment, but she walked independently with a short leg brace and a cane. Her comfortable gait speed was 0.57 m/s without an orthosis, and her 6-m walk test distance was 240 m. The Gait Assessment and Intervention Tool (G.A.I.T.) score was 35 points. After hospitalization, ankle robot training was performed daily, with RAGT performed 10 times in total. Post-intervention evaluation performed on Day 28 showed: FMA-LE, 23 points; comfortable walking speed, 0.69 m/s; G.A.I.T., 27 points; and three-dimensional motion analysis showed ankle dorsiflexion improved from 3.22° to 12.59° and knee flexion improved from 1.75° to 16.54° in the swing phase.

Discussion

: This is one of few studies to have examined the combination of two robots. Combining the features of each robot improved the gait pattern and motor function, even in the chronic phase.

Exoskeletal wearable robot on ambulatory function in patients with stroke: a protocol for an international, multicentre, randomised controlled study

INTRODUCTION

The purpose of this study is to determine the effect of overground gait training using an exoskeletal wearable robot (exoskeleton) on the recovery of ambulatory function in patients with subacute stroke. We also investigate the assistive effects of an exoskeleton on ambulatory function in patients with subacute stroke.

METHODS AND ANALYSIS

This study is an international, multicentre, randomised controlled study at five institutions with a total of 150 patients with subacute stroke. Participants will be randomised into two groups (75 patients in the robot-assisted gait training (RAGT) group and 75 patients in the control group). The gait training will be performed with a total of 20 sessions (60 min/session); 5 sessions a week for 4 weeks. The RAGT group will receive 30 min of gait training using an exoskeleton (ANGEL LEGS M20, Angel Robotics) and 30 min of conventional gait training, while the control group will receive 60 min conventional gait training. In all the patients, the functional assessments such as ambulation, motor and balance will be evaluated before and after the intervention. Follow-up monitoring will be performed to verify whether the patient can walk without physical assistance for 3 months. The primary outcome is the improvement of the Functional Ambulatory Category after the gait training. The functional assessments will also be evaluated immediately after the last training session in the RAGT group to assess the assistive effects of an exoskeletal wearable robot. This trial will provide evidence on the effects of an exoskeleton to improve and assist ambulatory function in patients with subacute stroke.

ETHICS AND DISSEMINATION

This protocol has been approved by the Institutional Review Board of each hospital and conforms to the Declaration of Helsinki. The results will be disseminated through publication.

TRIAL REGISTRATION NUMBER

Protocol was registered at ClinicalTrials.gov (NCT05157347) on 15 December 2021 and CRIS (KCT0006815) on 19 November 2021.

Effect of overground gait training with 'Mobility Assisted Robotic System-MARS' on gait parameters in patients with stroke: a pre-post study

OBJECTIVE

To observe the effect of overground gait training with 'Mobility Assisted Robotic System-MARS' on gait parameters in patients with stroke.

PATIENTS & METHODS

This prospective pre-post study was conducted in a tertiary teaching research hospital with 29 adult stroke patients, with age up to 65 years. Patients fulfilling the inclusion criteria were divided in 2 groups based on the duration of stroke (≤ 6 months-sub-acute & > 6 months-chronic stroke) and provided overground gait training with MARS robot for 12 sessions (1 h/session) over a period of 2-3 weeks. Primary outcome measures were; 10-Meter walk test-10MWT, 6-min' walk test-6MWT and Timed up & Go-TUG tests. Secondary outcome measures were Functional Ambulation Category-FAC, Modified Rankin Scale-MRS and Scandinavian Stroke Scale-SSS.

RESULTS

No adverse events were reported. Twenty-five patients who were able to perform 10-MWT at the beginning of study were included in the final analysis with 12 in sub-acute and 13 in chronic stroke group. All primary and secondary outcome measures showed significant improvement in gait parameters at the end of the training (p < 0.05) barring 10-Meter walk test in sub-acute stroke group (p = 0.255). Chronic stroke group showed significant minimum clinically important difference-MCID difference in endurance (6MWT) at the end of the training and both groups showed better 'minimal detectable change-MDC' in balance (TUG) at the end of the training.

CONCLUSIONS

Patients in both the groups showed significant improvement in walking speed, endurance, balance and independence at the end of the training with overground gait training with MARS Robot.

CLINICAL TRIAL REGISTRY

National Clinical Trial Registry of India (CTRI/2021/08/035695,16/08/2021).

Re-learning mental representation of walking after a brain lesion. Effects of a cognitive-motor training with a robotic orthosis

Introduction

Stroke-related deficits often include motor impairments and gait dysfunction, leading to a limitation of social activities and consequently affecting the quality of life of stroke survivors. Neurorehabilitation takes advantage of the contribution of different techniques in order to achieve more benefits for patients. Robotic devices help to improve the outcomes of physical rehabilitation. Moreover, motor imagery seems to play a role in neurological rehabilitation since it leads to the activation of the same brain areas as actual movements. This study investigates the use of a combined physical and cognitive protocol for gait rehabilitation in stroke patients.

Methods

Specifically, we tested the efficacy of a 5-week training program using a robotic orthosis (P.I.G.R.O.) in conjunction with motor imagery training. Twelve chronic stroke patients participated in the study. We evaluated balance and gait performance before and after the training. Six of them underwent fMRI examination before and after the training to assess the effects of the protocol on brain plasticity mechanisms in motor and imagery tasks.

Results

Our results show that the rehabilitation protocol can effectively improve gait performance and balance and reduce the risk of falls in stroke patients. Furthermore, the fMRI results suggest that rehabilitation is associated with cerebral plastic changes in motor networks.

Discussion

The present findings, if confirmed by future research, have the potential to advance the development of new, more effective rehabilitation approaches for stroke patients, improving their quality of life and reducing the burden of stroke-related disability.

Novel use of robot-assisted gait rehabilitation in a patient with stroke and blindness

Robot-assisted gait training (RAGT) is an effective adjunctive treatment for patients with stroke that helps to regain functional mobility and is applied in many rehabilitation units for poststroke neurorecovery. We discuss our successful attempt to apply RAGT in a patient with blindness that impeded his ability to maintain balance during gait training. He initially required two assistants to walk, but after undergoing conventional therapy with adjunctive RAGT, he improved to standby assistance for ambulation. There were also improvements in balance, activity tolerance and quality of life. Low-or-no vision states can affect the pace of recovery poststroke, but RAGT and conventional physiotherapy can possibly be combined in such patients to improve balance and motor outcomes. The Andago robot's safety features of weight support, harnessed suspension and walking mode selection supported our decision and enabled us to apply it safely for this patient.

Exoskeleton-based training improves walking independence in incomplete spinal cord injury patients: results from a randomized controlled trial

BACKGROUND

In recent years, ambulatory lower limb exoskeletons are being gradually introduced into the clinical practice to complement walking rehabilitation programs. However, the clinical evidence of the outcomes attained with these devices is still limited and nonconclusive. Furthermore, the user-to-robot adaptation mechanisms responsible for functional improvement are still not adequately unveiled. This study aimed to (1) assess the safety and feasibility of using the HANK exoskeleton for walking rehabilitation, and (2) investigate the effects on walking function after a training program with it.

METHODS

A randomized controlled trial was conducted including a cohort of 23 patients with less than 1 year since injury, neurological level of injury (C2-L4) and severity (American Spinal Cord Injury Association Impairment Scale [AIS] C or D). The intervention was comprised of 15 one-hour gait training sessions with lower limb exoskeleton HANK. Safety was assessed through monitoring of adverse events, and pain and fatigue through a Visual Analogue Scale. LEMS, WISCI-II, and SCIM-III scales were assessed, along with the 10MWT, 6MWT, and the TUG walking tests (see text for acronyms).

RESULTS

No major adverse events were reported. Participants in the intervention group (IG) reported 1.8 cm (SD 1.0) for pain and 3.8 (SD 1.7) for fatigue using the VAS. Statistically significant differences were observed for the WISCI-II for both the "group" factor (F = 16.75, p < 0.001) and "group-time" interactions (F = 8.87; p < 0.01). A post-hoc analysis revealed a statistically significant increase of 3.54 points (SD 2.65, p < 0.0001) after intervention for the IG but not in the CG (0.7 points, SD 1.49, p = 0.285). No statistical differences were observed between groups for the remaining variables.

CONCLUSIONS

The use of HANK exoskeleton in clinical settings is safe and well-tolerated by the patients. Patients receiving treatment with the exoskeleton improved their walking independence as measured by the WISCI-II after the treatment.

NeuroSuitUp: System Architecture and Validation of a Motor Rehabilitation Wearable Robotics and Serious Game Platform

BACKGROUND

This article presents the system architecture and validation of the NeuroSuitUp body-machine interface (BMI). The platform consists of wearable robotics jacket and gloves in combination with a serious game application for self-paced neurorehabilitation in spinal cord injury and chronic stroke.

METHODS

The wearable robotics implement a sensor layer, to approximate kinematic chain segment orientation, and an actuation layer. Sensors consist of commercial magnetic, angular rate and gravity (MARG), surface electromyography (sEMG), and flex sensors, while actuation is achieved through electrical muscle stimulation (EMS) and pneumatic actuators. On-board electronics connect to a Robot Operating System environment-based parser/controller and to a Unity-based live avatar representation game. BMI subsystems validation was performed using exercises through a Stereoscopic camera Computer Vision approach for the jacket and through multiple grip activities for the glove. Ten healthy subjects participated in system validation trials, performing three arm and three hand exercises (each 10 motor task trials) and completing user experience questionnaires.

RESULTS

Acceptable correlation was observed in 23/30 arm exercises performed with the jacket. No significant differences in glove sensor data during actuation state were observed. No difficulty to use, discomfort, or negative robotics perception were reported.

CONCLUSIONS

Subsequent design improvements will implement additional absolute orientation sensors, MARG/EMG based biofeedback to the game, improved immersion through Augmented Reality and improvements towards system robustness.

Control strategies used in lower limb exoskeletons for gait rehabilitation after brain injury: a systematic review and analysis of clinical effectiveness

BACKGROUND

In the past decade, there has been substantial progress in the development of robotic controllers that specify how lower-limb exoskeletons should interact with brain-injured patients. However, it is still an open question which exoskeleton control strategies can more effectively stimulate motor function recovery. In this review, we aim to complement previous literature surveys on the topic of exoskeleton control for gait rehabilitation by: (1) providing an updated structured framework of current control strategies, (2) analyzing the methodology of clinical validations used in the robotic interventions, and (3) reporting the potential relation between control strategies and clinical outcomes.

METHODS

Four databases were searched using database-specific search terms from January 2000 to September 2020. We identified 1648 articles, of which 159 were included and evaluated in full-text. We included studies that clinically evaluated the effectiveness of the exoskeleton on impaired participants, and which clearly explained or referenced the implemented control strategy.

RESULTS

(1) We found that assistive control (100% of exoskeletons) that followed rule-based algorithms (72%) based on ground reaction force thresholds (63%) in conjunction with trajectory-tracking control (97%) were the most implemented control strategies. Only 14% of the exoskeletons implemented adaptive control strategies. (2) Regarding the clinical validations used in the robotic interventions, we found high variability on the experimental protocols and outcome metrics selected. (3) With high grade of evidence and a moderate number of participants (N = 19), assistive control strategies that implemented a combination of trajectory-tracking and compliant control showed the highest clinical effectiveness for acute stroke. However, they also required the longest training time. With high grade of evidence and low number of participants (N = 8), assistive control strategies that followed a threshold-based algorithm with EMG as gait detection metric and control signal provided the highest improvements with the lowest training intensities for subacute stroke. Finally, with high grade of evidence and a moderate number of participants (N = 19), assistive control strategies that implemented adaptive oscillator algorithms together with trajectory-tracking control resulted in the highest improvements with reduced training intensities for individuals with chronic stroke.

CONCLUSIONS

Despite the efforts to develop novel and more effective controllers for exoskeleton-based gait neurorehabilitation, the current level of evidence on the effectiveness of the different control strategies on clinical outcomes is still low. There is a clear lack of standardization in the experimental protocols leading to high levels of heterogeneity. Standardized comparisons among control strategies analyzing the relation between control parameters and biomechanical metrics will fill this gap to better guide future technical developments. It is still an open question whether controllers that provide an on-line adaptation of the control parameters based on key biomechanical descriptors associated to the patients' specific pathology outperform current control strategies.